Restless Legs Syndrome (RLS) is a common, but under diagnosed neurological disorder of movement that affects around 10% of people. It is the cause of disturbed sleep, fatigue and stress as well as poor quality of life.
RLS should be suspect in anyone who has uncomfortable legs at night.
Definition and Diagnosis – is mainly derived from the symptoms
The irresistible need or urge to move the legs that results from uncomfortable leg sensations.
It can spread to other body parts eg arms, torso.
1. urge to move legs – can be overwhelming/ compelling
2. Motor restlessness with inactivity
3. Relief with movement eg walking, stretching
4. Worsening symptoms in evening and at night
Often confused with other conditions – only 6 % of people are correctly diagnosed
Symptoms
Women get this condition more than men
Sufferers describe ‘ water flowing in the legs, bugs in the bones, electricity in the legs, crawling, creeping, tingling, jittery, burning, deep-seated, ouchies, ants crawling, my legs need to walk, runaway legs, ”
Symptoms may be present all day but worsen at night, and during periods of inactivity. At night, 85% of patients have assoc with Periodic Limb Movements which can cause sleep problems which are often reported by the bed partner – involuntary, brief , rhythmic jerks of legs – last 0.5-5 secs, and occur every 20-40 secs
(PLM can also occur in Parkinsons disease and other conditions where dopamine is impaired.)
Sufferrers often complain of depression ( over 50% chance) , anxiety, lack of concentration, daytime drowsiness, impaired ability to work
It is a strong cause of sleep impairment
Children
• become restless – can be wrongly diagnosed with ADHD.
• Night time symptoms can be confused with “growing pains”
Cause of RLS
Unclear
Genetic – Primary type
Impaired Dopamine activity in Substantia NIgra which is in the brainstem part of the brain
Low iron in brain - iron is a co factor in dopamine production
Important implications
• Periodic Limb Movements are assoc with raised BP and heart rate
• RLS is assoc with increased risk of hypertension, heart disease and stroke, migraine, major Depressive disorder, Panic disorder
Types
Primary RLS
Starts at any age
More insidious than secondary RLS
More common in under 40’s
Likely to have a family member with it
Secondary RLS
More abrupt in onset
Typically occurs in association with another conditions
• iron deficiency – important for dopamine production in brain.
o Iron is needed for dopamine production in the brain. Dopamine helps control movement, amongst other things
o Note – you and your doctor need to get ferritin ( iron level indicator) levels above 60
• Pregnancy – especially third trimester – up to 30%.
o Associated with low iron +/- folic acid.
o In pregnancy, the iron requirement increases 3-4 fold, and the folic acid requirement increases 8-10 fold.
• End stage Renal failure – causes low iron, which can cause RLS
• Iron deficiency from other causes eg Cancer, other diseases
• Gastric surgery – low iron
• ADHD – probably low iron due to poor diet or absorption
• Folic acid def – a small group – Folic acid needed for Dopamine production
• Multiple Sclerosis – 38%
• Rheumatoid arthritis – 31%
• Diabetic Peripheral neuropathy
Treatment
If it’s the primary cause that runs in families, It often responds to Parkinsons drugs like Sinemet, or Madopar which increase dopamine in the brain.
If it’s the secondary cause, then find any underlying cause and treat that – see above.
In addition, some interventions could help:
• Weight reduction – obese are 1.5 times more likely to get RLS
• Correct deficiencies – Iron, Folic acid, B12, magnesium,
• Nap is possible between 6am – 12MD when its milder
• Good sleep hygiene – go to bed early and regularly
• Moderate, regular exercise
• Hot baths, leg massage, leg vibration.
• Avoid aggravators
• Alcohol
• Nicotine
• Fatigue / stress
• Foods
o tannins eg wines/ tea – interfere w iron absorption
o high carbohydrate load in some
• Avoid drugs that aggravate
• Metoclopamide
• Neuroleptics
• Antidepressants – ironically used to treat the depression they get
• Antihistamines – ironically, used as OTC sleep aids
• Good sleep habits
• Avoid RLS triggers eg TV, caffeine, nicotine, alcohol close to bedtime
• Drug therapy – if disturbs sleep at least 3 nights per week
• Dopamine agonists
• – L-Dopa – SE’s include sedation, nausea, headache, augmentation ( starts earlier, and spreads to other parts of body)
• New dopamine agonist – ropinirole – used for Parkinsons disease
• Gabapentin
• Benzodiazepines
• Opioids - OK in pregnancy
